Cooperating for better care.

News & Views

How a hospital’s coordinated-care teams help keep post-discharge patients on track

Share this:


Herewith a look at how coordinated-care teams are helping patients succeed in their post-hospital-discharge care in the face of the patients’ low health literacy and problems understanding the importance of medication adherence, especially involving multiple medications prescribed for chronically ill people.

This FierceHealthcare article looks at how the 455-bed South Nassau Communities Hospital, in Oceanside, N.Y., does post-discharge coordinated care.

Some of its tactics, as summarized by FierceHealthcare:

  • “A cardiac health program, where patients are counseled weekly for the first four weeks after discharge by specialist caregivers, including pharmacists, dietitians and nurse practitioners.
  • “A hotline number that connects patients to those caregivers if they have any questions.
  • “Similar counseling for all patients based on risk factors such as prior admissions and for psychiatric patients, who are often at risk for poor medication compliance.
  • Education about when to take–and when not to take–certain medications that could, for example, interfere with sleep.”
To read more, please hit this link.

Contact Info

(617) 230-4965

Wellesley, Mass